Sec. 10.09.35.08. Payment Procedures

A. Reimbursement Principles.

(1) The Program shall pay the provider at one of four rates for each day that the participant is under the provider's care, subject to the conditions, limitations, and exceptions set forth in this chapter.

(2) The payment rates for providers shall be those established by the Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services for hospice care under a Medical Assistance Program.

(3) The daily rates are prospective rates, and there shall be no retroactive adjustment of payment other than the limitation on payment for inpatient care set forth in §C of this regulation.

B. Categories of Hospice Care for Reimbursement.

(1) Routine Home Care.

(a) The provider shall be paid the routine home care rate for each day the participant is under the care of the provider and another rate is not payable under §B(2)-(4) of this regulation.

(b) The routine home care rate is paid without regard to the volume or intensity of covered services provided on a given day.

(2) Continuous Home Care.

(a) The provider shall be paid the continuous home care rate for each day the participant is at home, under the care of the provider, and all of the following requirements are met:

(i) There is a brief period of crisis during which the participant requires continuous care, which is primarily nursing care to achieve palliation or management of acute medical symptoms.

(ii) Nursing care shall be provided by either a registered nurse or a licensed practical nurse, and a nurse must be providing care for more than half the period. Homemaker or home health aide services may be provided to supplement the nursing care.

(iii) A minimum of 8 hours of care must be provided during a 24-hour day which begins and ends at midnight, but the hours of care need not be continuous.

(b) The continuous home care rate is divided by 24 hours to arrive at an hourly rate.

(c) For every hour or part of an hour of continuous home care furnished, the hourly rate shall be paid to the provider, up to 24 hours a day.

(d) If less skilled care is needed on a continuous basis to maintain the patient at home during a period of crisis, or if less than 8 hours of continuous home care is provided during a day, payment shall be made at the routine home care rate.

(3) Inpatient Respite Care.

(a) The provider shall be paid the inpatient respite care rate for each day the participant is in a qualified inpatient facility for the purpose of respite care, subject to the following requirements:

(i) Payment shall be made at the inpatient respite care rate for a maximum of 5 consecutive days at a time, including the day of admission but not counting the day of discharge;

(ii) Payment for the sixth and any subsequent day of inpatient respite care shall be made at the routine home care rate;

(iii) For the day of discharge, payment shall be made at the routine or continuous home care rate, as appropriate, unless the participant dies as an inpatient; and

(iv) Payment shall be made at the inpatient respite care rate for the day of discharge if the participant is discharged deceased.

(b) Inpatient respite care may not be provided when the participant is a resident of a nursing facility.

(4) General Inpatient Care. The provider shall be paid the general inpatient care rate for each day the participant is in a qualified inpatient facility for care, subject to the following requirements:

(a) The inpatient care is required for procedures necessary for pain control or for acute or chronic symptom management which cannot be provided in other settings;

(b) Payment shall be made at the general inpatient rate for the day of admission and for all subsequent inpatient days, except for the day of discharge;

(c) For the day of discharge, payment shall be made at the routine or continuous home care rate, as appropriate, unless the participant dies as an inpatient; and

(d) Payment shall be made at the general inpatient rate for the day of discharge if the participant is discharged deceased.

C. Limitation on Payment for Inpatient Care.

(1) Payment to a provider for inpatient care shall be limited according to the total number of days of inpatient care the provider furnished to participants during a specific cap period, excluding the days of inpatient care furnished to participants diagnosed with Acquired Immune Deficiency Syndrome (AIDS).

(2) For the cap period, the aggregate number of inpatient days reimbursed for general inpatient and inpatient respite care (excluding inpatient days reimbursed for participants with AIDS) may not exceed 20 percent of the aggregate total number of days of hospice care the provider furnished to all participants (excluding days of hospice care furnished to participants with AIDS) during the same period.

(3) The limitation on payment for inpatient care days is calculated as follows:

(a) Subtract the days of care furnished to participants with AIDS from the total days of care furnished by the provider to all participants during the cap period;

(b) Subtract the days of inpatient care furnished to participants with AIDS from the total days of inpatient care furnished by the provider to all participants during the cap period;

(c) The maximum allowable number of reimbursable inpatient days is determined by multiplying by 0.2 the adjusted total number of days of hospice care the provider furnished to participants during the cap period, as determined in §C(3)(a) of this regulation;

(d) If the adjusted total number of inpatient care days the provider furnished to participants during the cap period, as determined in §C(3)(b) of this regulation, is less than or equal to the maximum allowable number of reimbursable inpatient days, no payment adjustment is necessary; and

(e) If the adjusted total number of inpatient care days the provider furnished to participants during the cap period exceeds the maximum allowable number of reimbursable inpatient days, the payment limitation and the refund to the Program shall be determined by:

(i) Calculating a ratio of the maximum allowable number of reimbursable inpatient days to the adjusted total number of inpatient care days, and multiplying this ratio by the total reimbursement to the provider during the cap period for general inpatient and inpatient respite care days (minus the reimbursement for inpatient care days furnished to participants with AIDS);

(ii) Multiplying excess inpatient care days by the routine home care rate;

(iii) Adding together the amounts calculated in §C(3)(e)(i) and (ii) of this regulation; and

(iv) Refunding to the Program the difference between the interim reimbursement made for non-AIDS inpatient care during the cap period and the amount determined in §C(3)(e)(iii) of this regulation.

(4) This limitation shall be applied once a year, at the end of the cap period.

D. Payment for Physician Services.

(1) The per diem rates are designed to reimburse for those administrative and general supervisory activities performed by physicians who are employees of or are working under arrangements with the provider. These activities are generally performed by the physician serving as the medical director or the physician member of the provider's interdisciplinary group. The included activities consist of participation in establishment of care plans, supervision of service delivery, periodic review and updating of care plans, and establishment of governing policies.

(2) In addition to the daily rates, the Program shall make separate payment to the provider for physician services, subject to the following requirements:

(a) The services shall be direct patient care services furnished to a participant under the care of the provider;

(b) The services shall be furnished by an employee of the provider or furnished under arrangements made by the provider;

(c) The provider shall have a liability to reimburse the physician for the services rendered;

(d) The provider shall bill for the physician services in accordance with procedures established by the Program;

(e) A payment may not be made for physician services furnished on a volunteer basis; and

(f) Payment to the provider for physicians' services shall be made in accordance with the fee schedule contained in COMAR 10.09.02.

(3) A physician who is designated as the attending physician by a participant and who also volunteers services to the provider is considered an employee of the provider, whose direct patient care services furnished to the participant on a nonvolunteer basis shall be reimbursed to the provider in accordance with §D(2) of this regulation.

(4) A physician who is designated as the attending physician by a participant and who is not an employee of the provider or receiving compensation from the provider shall be paid by the Program in accordance with COMAR 10.09.02. The attending physician may bill the Program only for personal professional services.

E. When a participant resides in a nursing facility, the Program shall pay an additional per diem amount for room and board to the provider, subject to the following requirements:

(1) The additional amount shall be paid only for those days that the provider is reimbursed at the routine or continuous home care rate for hospice care furnished to the participant;

(2) The amount shall be the per diem reimbursement established by the Program to pay for room and board in the facility;

(3) The amount shall be paid to the provider only when the provider and the facility have a written agreement under which the provider is responsible for the professional management of the participant's hospice care and the facility agrees to provide room and board to the participant;

(4) While the provider is being reimbursed for hospice care furnished to a participant residing in a nursing facility, Program payment to the facility shall be discontinued; and

(5) The Department of Human Services shall determine the application of a recipient's resource to the cost of hospice care pursuant to COMAR 10.09.24 and COMAR 10.09.25. The provider:

(a) Shall collect a recipient's resource available for hospice care as certified by the Department of Human Services,

(b) May not collect a total payment, including the recipient's resource and the Department's payment, which exceeds the amount the provider would be paid in accordance with this regulation for a day of hospice care, and

(c) Shall show sums collected from a recipient's available resource as patient collection.

F. Requests for Payment. Requests for payment for hospice care services rendered shall be submitted as set forth in COMAR 10.09.36.04.

G. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.